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Resistant Hypertension: Get Your Questions Answered

Online Health Chat with George Thomas, MD

May 15, 2014

Description

Having high blood pressure is a major health issue and it becomes even more disconcerting when you are on multiple medications without any improvements. This is known as resistant hypertension, and can lead to serious health conditions. The most important thing is to ask your physician questions on how you can get your blood pressure under control.

According to the American Heart Association, one in three Americans have been diagnosed with high blood pressure. However, only about half of those who have hypertension actually have it under control. Uncontrolled hypertension can lead to heart failure, stroke, and kidney disease. Seeking early treatment is the key to preventing the potentially serious consequences of hypertension.

About the Speaker

George Thomas, MD, is an associate staff physician and Director of the Center for Blood Pressure Disorders at Cleveland Clinic’s Department of Nephrology and Hypertension within the Glickman Urological & Kidney Institute. He is board certified in internal medicine and nephrology.

Dr. Thomas completed his fellowship in nephrology and hypertension at Cleveland Clinic following his residency in internal medicine at Tufts University-St Elizabeth’s Medical Center, in Boston. He has also completed a graduate program in public health at Johns Hopkins School of Hygiene & Public Health, in Baltimore. Dr. Thomas attended medical school at Bharati Vidyapeeth Medical College in Mumbai, India.

Dr. Thomas is certified as a hypertension specialist by the American Society of Hypertension, and is a Fellow of the American College of Physicians. His specialty interests include resistant hypertension, electrolyte abnormalities, chronic kidney disease, end stage renal disease, glomerular disease and kidney stones. Dr. Thomas sees patients at Cleveland Clinic main campus and Richard E. Jacobs Health Center.


Let’s Chat About Resistant Hypertension: Get Your Questions Answered

Moderator: Let's get started with our questions.


Resistant Hypertension

sammt: What is the typical patient that you see with resistant hypertension? Is there a typical age, gender, ethnicity, chronic conditions, etc.?

George_Thomas,_MD: Being of older age, female gender, overweight, and African American race are some factors that have been associated with resistant hypertension.

Felipe: What exactly qualifies as resistant hypertension? Does it have to be causing kidney damage or just blood pressure that won't come down with medication?

George_Thomas,_MD: Resistant hypertension is blood pressure that stays above goal despite being on at least three medications (from different classes) including a water pill. This does not necessarily mean the presence of any organ damage, but uncontrolled blood pressure can certainly lead to organ damage.

Felipe: Would you explain what happens with kidney function when blood pressure is not controlled and diagnosed as resistant?

George_Thomas,_MD: Uncontrolled blood pressures over the long term can lead to organ damage, including heart failure, stroke and kidney disease. The kidneys are affected because the small blood vessels supplying the kidney are progressively injured when the blood pressures are high—eventually affecting kidney function.

By definition, resistant hypertension is a term that is used when at least three medications are being taken (including a water pill) and blood pressure remains uncontrolled (above goal), which leads to organ damage.

MrCurious: What causes high blood pressure to develop after the age of 40 years old—particularly for people who have a healthy weight and BMI, non-smoker, and have no other health issues other than being more sedentary? Also, why do medications for blood pressure work effectively for a while (years) and then become ineffective later? Does this mean the underlying cause is getting worse? My fear is that the cause is hardening of the arteries (plague buildup).

George_Thomas,_MD: High blood pressures are more common in older age due to changes occurring in the blood vessels. Even with a healthy weight and being a non-smoker, other factors like a strong family history, lack of exercise, high-salt diet, and increased alcohol consumption can predispose someone to the development of high blood pressure. There may be a number of reasons for blood pressure medications not to work effectively, which can include blood vessel changes, medications that may interfere with blood pressure control (like NSAIDs), and the above-mentioned factors.


Primary vs. Secondary Hypertension

celine: What is meant by primary or secondary hypertension?

George_Thomas,_MD: Primary hypertension is the term used to denote hypertension that cannot be attributed to one specific cause. About 90 to 95 percent of people with hypertension have primary hypertension. The risk factors for developing hypertension including older age, being overweight, and eating a high-salt diet.

Secondary hypertension is the term used to denote hypertension that is due to a hormonal or vascular cause—about five percent of people have this. Physicians usually assess for secondary causes if blood pressure is uncontrolled despite medications, or if there are other clues like abnormal electrolyte levels or other findings on examination.


Recent Hypertension

misslottie: At 61 years old, I never had high blood pressure until a few months ago. All of a sudden for no reason it was high at 180/100 or worse, but after a few weeks of utter confusion now it is back pretty low 137/80. I would like for it to be 120/80. I had to experiment with a few drugs and doses from the doctor and I have settled on Cardizem® (diltiazem, a calcium channel blocker) 60 mg twice a day as I have occasional atrial fibrillation (a-fib) like once a year. The problem is that 120 mg is just barely the right dose. I am still at 135 to 140/80. We found 180 mg is too much, making my blood pressure too low—like 90/60.I need to add something in a small dose to get complete coverage of my blood pressure 24/7. I cannot take those ACE (angtiotensin-converting-enzyme) inhibitors—they make me dizzy. What would you suggest? I take a water pill already.

George_Thomas,_MD: Most current guidelines suggest a goal blood pressure of less than 140/90 for patients with a diagnosis of hypertension and taking medications. If your blood pressure is below this range, your risk for having cardiovascular complications due to hypertension is low. At this point, I would suggest more intensive lifestyle modification, including a low-sodium diet, physical activity (if this is possible), weight loss (if you are overweight) and moderating alcohol consumption. If there is concern for a lot of variation in blood pressure, your doctor can possibly order a 24-hour blood pressure monitor for you to assess blood pressure patterns through the course of the day and at night.


Cardiac Abnormalities and High Blood Pressure

Joyy : My mom is 77 years old, and is in China now. She has had high blood pressure for more than 20 years. Her blood pressure usually is high in the early morning, around 5 a.m., and it can be 160. After 8 a.m. it returns to normal. The reports of color Doppler ultrasound are as follows:

  1. Ascending aorta aneurysm with continuous extension,
  2. Aorta atherosclerosis and lightly aortic valve degeneration, slightly unable to fully close,
  3. Sectional movement abnormality at the low inferior left ventricle; reduced diastolic function of left ventricle,
  4. Mild tricuspid valve is unable to close fully, increased pressure in pulmonary arteries and increased right ventricle systolic pressure, and reduced diastolic function of the right ventricle.

The medicine she takes seems to not be working well. What medicine would you suggest? Also what time should she take her medicine? (She takes them now at around 8 a.m.).

George_Thomas,_MD: It would be difficult to give specific advice regarding types or names of medications to take without a complete evaluation. In general, taking long-acting medications rather than short-acting ones gives more sustained control over a 24-hour period. The imaging results that you presented do not mention kidney arteries (sometimes blockages in kidney arteries can cause high blood pressures). I would strongly recommend seeing a cardiologist or a vascular surgeon to have the ascending aorta aneurysm evaluated. As far as timing of medications, some studies show that taking at least one blood pressure medication at bed-time may be beneficial. This may be considered in a discussion with her current physician.


Medication Changes

rhodge9732: I recently have been having medication changes to get my blood pressure under control. I'm now taking Taztia XT® (diltiazem hydrochloride) 240 mg once in the morning. My last visit to the doctor in the morning my pressure was 140-“something” over 98. I started tracking my pressure at various times of day. In the morning it averages 143/93. At midday it averages 141/83. In the evening it is 133/79. Would it be a good idea to cut the dose to 120 mg and take twice per day or even increase it to 180 mg and take twice daily to level out the pressure? If this is a good idea, should I wait until my four-month follow up?

George_Thomas,_MD: Long-acting medications typically have lasting effect over 24 hours. However, in some cases, dosing this as twice a day may help. It would be OK to try dosing this as 120 mg twice daily (if you able to cut the pills) and reassessing what the blood pressures are. You should monitor your heart rate on this medication as well.

Virginia: I am 89 years old with COPD (chronic obstructive pulmonary disease) and taking Diovan® (valsartan) for high blood pressure. Prinivil® (lisinopril) was causing me to cough. Are there any other medications that could be tried instead of Diovan®? Or do you think the generic version will be available soon?

George_Thomas,_MD: I believe that a generic version of Diovan® may be available soon, although it is unclear when exactly. Other options would be medications within the same class like Cozaar® (losartan). You could discuss this with your doctor.


Medication Reactions and Interactions

LucyintheSkies: I was taking Mobic® (meloxicam) 15 mg for arthritis in my hands. My blood pressure has been steadily increasing to the point of 169/81 last week. We decreased the dose of Mobic® and I am supposed to keep track of my blood pressure. How often should I check it? It seems like when they do a series of five blood pressure readings in the office with the machine it is high, yet much lower when done the old fashioned, traditional way with a sphygmomanometer and stethoscope. Genetically I am doomed for high blood pressure and high cholesterol, but I don't want to get to the point of having problems with my heart or kidneys. Do you have any suggestions?

George_Thomas,_MD: The class of medications called NSAIDs (which includes meloxicam) can interfere with blood pressure control, especially if it is being taken regularly. If you check blood pressures at home, make sure that you use a machine with an arm cuff. Sit down quietly for at least five minutes, your back should be supported, your legs should be uncrossed on the ground, and the arm on which blood pressure is being taken should be at heart level. Wait for at least 30 minutes before checking blood pressure if you have had caffeine. You can check blood pressures two times in the morning on waking up and two times in the evening before going to bed. Check at least three times a week (or more often if your doctor recommends this). What we typically look for is a pattern of high blood pressures rather than a single isolated reading. The goal blood pressure for most people who have a diagnosis of hypertension or are taking medications is less than 140/90. Although you may have a family history of hypertension that makes your more susceptible to have high blood pressure, you can take certain steps, including a low-salt diet, physical activity (as able), and limiting alcohol consumption.

rampanand: Is long-term use of Tenormin® (atenolol) known to cause persistent throat irritation?

George_Thomas,_MD: I am not aware that this medication can cause persistent irritation in the throat, although it cannot be discounted as a possible side effect. You may want to have an ENT (ear, nose, and throat) specialist evaluate you for this


High Blood Pressure and Proteinuria

ccligal: I have had proteinuria for the last 10 years that is regulated via blood pressure medications 320 mg Diovan® (valsartan) and amlodipine. (I switched from Vasotec® [enalapril] based on recent guidelines.) My average blood pressure is 117/80. My microalbumin/creatinine ratio is 1011, my urine total protein is 1506, and my protein total urine is 1659. I don't understand these last three readings. My AST is 46, and my ALT is 79. To reduce obesity, I am starting the Medifast® program. I am also a well-controlled diabetic on Metformin® (metformin hydrochloride) 1000 mg twice daily. My HbA1c is currently 7—an all time high, since it is usually 6. Would you have any concerns about Medifast®? Understand Medifast® puts patient into mild ketosis, but the benefit seems to outweigh the risk (pun intended). Do you agree?

George_Thomas,_MD: It sounds like you have proteinuria due to diabetes. Diovan® is a good medication in this setting. Your blood pressure seems well controlled, and your diabetes seems to be reasonably well controlled (other than the recent bump in your HbA1c for which you may want to watch your blood sugars more closely). I'm not familiar with the Medifast® diet, but it sounds like it may be a high protein diet. While this may help with weight loss, I would be wary about a high protein diet in your case (due to proteinuria). You should discuss alternatives with your physician or nutritionist.

ccligal: What do you think of the option of Medifast® based on the numbers I supplied earlier? My nephrologist reluctantly agreed since I am gaining weight and am at an all time high. My BMI is over 40. However, my endocrinologist was unresponsive. The following was from a doctor's letter supplied by Medifast® to be shared with my doctor, "In the first phase your patient will consume between 900 to 1000 calories daily, and maintain a 1:1 balance of carbohydrates and protein (80-100 g). This low carbohydrate intake fosters a safe mild state of ketosis (fat burning), while preserving muscle. Patients ordinarily lose between 8 to 20 lbs per month with good adherence."

George_Thomas,_MD: I would be hesitant, as your nephrologist was, to recommend a high protein diet in the setting of proteinuria. You will need to discuss with an endocrinologist and a nutritionist who specializes in weight loss programs, specifically in the context of proteinuria. If you do decide to proceed with this diet, your proteinuria and kidney function should be closely monitored. There may be a number of reasons for your blood pressure medications not to work effectively, which can include blood vessel changes, taking medications which may interfere with blood pressure control (like NSAIDs), and the above-mentioned factors.


Home Blood Pressure Monitors

lillian: Are all home blood pressure monitors created equal? Should you use a cuff for the upper arm or lower arm? (I think I have seen these.)

George_Thomas,_MD: Most home monitors are good. You may want to check individual reports on consumer websites like Consumer Reports to get comparative rankings. What I would recommend is using a blood pressure cuff that goes on the upper arm rather than the wrist, and to bring your home monitor to your doctor's office during your visit to compare readings that the doctor gets with your own machine's readings. Keep in mind that the cuff you use should properly fit as well.


Closing

Moderator: I am sorry to say that our time with Dr. George Thomas is now over. Thank you for sharing your expertise and time to answer questions today.

George_Thomas,_MD: Thank you for your questions.


For Appointments

If you would like to make an appointment with Dr. Thomas or any of our other nephrologists in the Glickman Urological & Kidney Institute, please call 800.223.2273 x46771 or request an appointment online by visiting www.clevelandclinic.org/appointments.


For More Information

On Hypertension
On Cleveland Clinic

The Department of Nephrology and Hypertension within Cleveland Clinic’s Glickman Urological & Kidney Institute has a rich history of innovation and research in hypertension. The department’s Center for the Study of Blood Pressure and Fluid/Electrolyte Disorders provides specific expertise in these areas, and is staffed by American Society of Hypertension (ASH) certified hypertension specialists, with a laboratory and equipment dedicated to hypertension evaluation and testing.

Besides the standardized use of automated blood pressure devices in our outpatient clinics, we have a large cohort of patients who undergo 24-hour ambulatory blood pressure measurements to help with diagnosis of white coat hypertension, masked hypertension, labile hypertension, and assessment of nocturnal dipping and efficacy of therapy. We also use noninvasive hemodynamic testing with impedance cardiography to help guide treatment decisions and tailor therapy by assessing neuro-humoral profiles and hemodynamic parameters in our hypertension lab. We assess central blood pressure indices using applanation tonometry, including pulse wave analysis and pulse wave velocity. We also have the capability to study endothelial function non-invasively, which could help early detection of endothelial dysfunction for assessment of cardiovascular risk.

The Center has expertise in the field of secondary hypertension management, specifically related to the diagnosis and management of primary hyperaldosteronism, pheochromocytoma, and renal artery stenosis; as well as electrolyte disorders.

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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.


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Reviewed: 05/14

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